Menopause intake that asks what your team actually needs to know
Ask about menopause stage, symptoms like hot flashes and sleep disruption, and any post-menopause bleeding, then collect hormone therapy history and recent bloodwork before a slot is booked.
Preview your menopause care intake
Explore 5 questions from the Menopause Care template. This interactive preview uses illustrative scoring and sample attachments. Open the full survey to try the complete intake.
What a qualified menopause care lead should tell you
Evaluation of where a patient sits in the perimenopause-to-postmenopause transition, the symptoms driving her to seek care, any postmenopausal bleeding, and her hormone therapy and existing-provider status.
- Stage Best Describes Where
- Symptoms Affecting Most Right
- Had Any Bleeding After
- Taking Or Have Previously
- Have Doctor Or Clinic
The questions your team needs answered
Every menopause care intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| Which stage best describes where you are in this transition? | The stage answer signals whether the patient is likely still cycling, in transition, or fully postmenopausal, which shapes what kind of appointment is appropriate. |
| Which symptoms are affecting you most right now? | The specific symptoms selected, especially hot flashes, sleep problems, and irregular bleeding, show how much the transition is affecting daily life and which concerns need attention first. |
| Have you had any bleeding after having no periods for a year or more? | A yes answer here flags bleeding after a year without periods, a finding that needs clinical evaluation rather than a routine follow-up slot. |
| Are you currently taking or have you previously taken hormone therapy for these symptoms? | Knowing whether the patient is currently on therapy, has stopped it, or never started tells your team if the visit is a therapy review or a first discussion. |
| Do you have a doctor or clinic you currently see regularly? | Whether she already sees a doctor regularly helps your team understand if this practice will be her primary source of menopause care or a supplemental visit. |
How Cliont scores menopause care leads
Configured answer weights help your team prioritize follow-up. Your team reviews each submission and decides the next step.
Value signals
- Having symptoms, periods still occurring
- No periods for several months to a year
- No periods for over a year
- Not sure
- Hot flashes or night sweats
- Sleep problems
See an example lead handoff
Illustrative lead details and score show how a submission can reach your team.
Menopause Care Lead
From first click to qualified lead
Follow patients and caregivers through one smooth, guided flow.
They land & meet you
Your video greeting plays instantly — a real face instead of a blank form.
They explain the visit
Smart questions adapt to their visit and capture the full scope.
They share details
Symptoms, history, and documents come attached before the visit.
You get a ready lead
Scored and qualified — waiting for you to win it.
Built for menopause care workflows
| Cliont capability | Menopause Care application |
|---|---|
| Weighted lead scoring | Stage and symptom answers like hot flashes, sleep problems, and mood changes are weighted so symptomatic perimenopausal and postmenopausal patients surface ahead of vague inquiries. |
| High-priority flagging | A yes answer on bleeding after a year without periods raises the lead's priority so it isn't scheduled the same way as a routine symptom check-in. |
| Document collection before the visit | Patients can attach hormone panel results or a symptom diary alongside their intake so the record isn't blank when the appointment is booked. |
| CRM routing | Completed intakes carry stage, symptom, bleeding, and hormone therapy answers into your CRM together, so staff aren't booking a generic slot without that context. |
Example menopause care lead scenarios
Illustrative situations explain the intake questions and possible follow-up.
Still cycling, symptoms disrupting sleep
A patient still having periods reports hot flashes and sleep problems as her main complaints, scoring high on the symptom-burden signals without any bleeding concern.
Bleeding after a year without periods
A patient who hasn't had a period in over a year answers yes to bleeding since then, a response the intake weights heavily so it can be prioritized ahead of a routine follow-up.
Not sure which stage she's in
Some patients select 'not sure' for their stage, which the intake still scores and forwards rather than filtering out, since clarifying the stage is itself part of the visit.
Established patient adjusting current therapy
A patient already taking hormone therapy who also sees a regular provider is captured differently than a new inquiry, since the visit is likely a review rather than a first consult.
New patient with no existing provider
Someone who has never taken hormone therapy and has no regular doctor answers both questions no, signaling she may need a fuller intake conversation before any treatment discussion.
Connect Cliont to your workflow
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Notify your team
Email, SMS, Slack
Configure other destinations
Google Sheets, configured webhooks, Zapier and API workflows
Simple, transparent pricing
Choose the plan that works for your business.
Professional
Unlimited intake forms and leads for your growing business.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Advanced analytics dashboard
Pay Per Lead
Only pay when you receive a qualified lead.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Charged only for submitted leads
More women's health intake templates
Menopause Care lead-intake FAQs
How does the intake handle a patient who reports bleeding after menopause?
The bleeding-after-a-year question is a direct yes/no with a high weight on 'yes,' so a patient reporting postmenopausal bleeding scores higher and can be flagged for closer review rather than slotted into a routine follow-up.
Can a patient select more than one symptom?
Yes, the symptom question is multi-select, so a patient reporting hot flashes, sleep problems, and mood changes together shows up with the combined symptom picture in one submission.
Does the form ask whether someone is already on hormone therapy?
Yes, patients indicate whether they're currently taking it, took it in the past, or never have, which helps your team distinguish a therapy-review visit from a first-time consultation before the appointment is booked.
What happens if a patient doesn't know what stage of menopause she's in?
The stage question includes a 'not sure' option that's still scored and passed through to your CRM, since clarifying the stage is often part of what the visit is for rather than a reason to filter someone out.
Does the intake check whether the patient has a regular doctor?
Yes, it asks whether she currently sees a doctor or clinic regularly, which gives your team context on whether this visit is likely to be her primary source of care or a supplemental consultation.
What can patients upload before their appointment?
Patients can attach recent hormone panel or bloodwork results, a current medication list, and any symptom or bleeding diary they've kept, so your team has that detail before the visit starts.
Turn menopause care visitors into qualified patients
Give every menopause care visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.